Rationing or rationalizing children's medical care: comparison of a Medicaid HMO with fee-for-service care

Pediatric outpatient utilization by differing Medicaid payment models in the United States

BACKGROUND

In the United States (US), Medicaid capitated managed care costs are controlled by optimizing patients' healthcare utilization. Adults in capitated plans utilize primary care providers (PCP) more than emergency departments (ED), compared to fee-for-service (FFS). Pediatric data are lacking. We aim to determine the association between US capitated and FFS Medicaid payment models and children's outpatient utilization.

METHODS

This retrospective cohort compared outpatient utilization between two payment models of US Medicaid enrollees aged 1-18 years using Truven's 2014 Marketscan Medicaid database. Children enrolled > 11 months were included, and were excluded for eligibility due to disability/complex chronic condition, lack of outpatient utilization, or provider capitation penetration rate < 5% or > 95%. Negative binomial and logistic regression assessed relationships between payment model and number of visits or odds of utilization, respectively.

RESULTS

Of 711,008 children, 66,980(9.4%) had FFS and 644,028(90.6%) had capitated plans. Children in capitated plans had greater odds of visits to urgent care, PCP-acute, and PCP-well-child care (aOR 1.21[95%CI 1.15-1.26]; aOR 2.07[95%CI 2.03-2.13]; aOR 1.86 [95%CI 1.82-1.91], respectively), and had lower odds of visits to EDs and specialty care (aOR 0.82 [95%CI 0.8-0.83]; aOR 0.61 [95%CI 0.59-0.62], respectively), compared to FFS.

CONCLUSIONS

The majority of children in this US Medicaid population had capitated plans associated with higher utilization of acute care, but increased proportion of lower-cost sites, such as PCP-acute visits and UC. Health insurance programs that encourage capitated payment models and care through the PCP may improve access to timely acute care in lower-cost settings for children with non-complex chronic conditions.

Effect of privatized managed care on public insurance spending and generosity: Evidence from Medicaid

States choose to provide Medicaid coverage via managed care or traditional fee-for-service. Managed care provided by private insurers poses higher contracting costs and information asymmetry than traditional fee-for-service but potentially improves efficiency and reduces spending. Evaluating the effect of managed care on Medicaid spending is challenging because adoption of managed care is nonrandom and may be driven by local economic shocks that simultaneously affect Medicaid spending. This study implements a dynamic panel framework to estimate the effect of managed care enrollment on spending levels and program design. Results show reductions in Medicaid spending larger than previously found in cross-state studies: A 10% increase of managed care enrollment reduces state Medicaid spending by 2.94%, or approximately $55 million. The study identifies which areas of spending are differentially affected by managed care enrollment and whether savings from managed care affect Medicaid design, specifically coverage generosity.

Effects of Medicaid managed care programs on health services access and use

OBJECTIVE

To estimate the effects of Medicaid managed care (MMC) programs on Medicaid enrollees' access to and use of health care services at the national level.

DATA SOURCES/STUDY SETTING

1991-1995 National Health Interview Surveys (NHIS) and a 1998 Urban Institute survey on state Medicaid managed care programs.

STUDY DESIGN

Using multivariate regression models, we estimated the effect of living in a county with an MMC program on several access and use measures for nonelderly women who receive Medicaid through AFDC and child Medicaid recipients. We focus on mandatory programs and estimate separate effects for primary care case management (PCCM) programs, health maintenance organization (HMO) programs, and mixed PCCM/HMO programs, relative to fee-for-service (FFS) Medicaid. We control for individual and county characteristics, and state and year effects.

DATA COLLECTION/EXTRACTION METHOD

This study uses pooled individual-level data from up to five years of the NHIS (1991-1995), linked to information on Medicaid managed care characteristics at the county level from the 1998 MMC survey.

PRINCIPAL FINDINGS

We find virtually no effects of mandatory PCCM programs. For women, mandatory HMO programs reduce some types of non-emergency room (ER) use, and increase reported unmet need for medical care. The PCCM/HMO programs increase access, but had no effects on use. For children, mandatory HMO programs reduce ER visits, and increase the use of specialists. The PCCM/HMO programs reduce ER visits, while increasing other types of use and access.

CONCLUSIONS

Mandatory PCCM/HMO programs improved access and utilization relative to traditional FFS Medicaid, primarily for children. Mandatory HMO programs caused some access problems for women.

Children's use of mental health services in different Medicaid insurance plans

This study examined the effect of different Medicaid insurance plans on children's mental health service use through survey, claims, and encounter data collected between February 1998 and February 1999. Participants were assigned to 1 of 3 insurance plans: fee-for-service, a Health Maintenance Organization and a prepaid carve-out. Logistic and stratified logistic regression were used to examine the effect of plan on service utilization, adjusting for caregiver report of need for services and psychosocial functioning. There was no difference in service use by plan controlling for demographic characteristics; however, when psychopathology and caregiver report of need for services were included in the model, the odds of using services in the Health Maintenance Organization was half of and the odds in the carve-out 29% less than the odds of using services in fee-for-service. Characteristics of the interaction between need, psychopathology, and insurance plan that may be associated with the reduction in service use are discussed.

Impacts of Medicaid managed care on children

OBJECTIVE

To assess the impact of switching from a fee-for-service (FFS) delivery system to managed care on access to, use of, and satisfaction with health care for children.

DATA SOURCES/STUDY SETTING

A 1998 survey of Medicaid recipients in rural Minnesota.

STUDY DESIGN

Using a quasi-experimental framework, we compare the experiences of children on Medicaid living in counties that had switched to managed care with those of children living in counties operating under FFS Medicaid. We address the impact of Medicaid managed care (MMC) on access to, use of, and satisfaction with care.

DATA COLLECTION METHODS

A stratified random sample of children on Medicaid was drawn based on Medicaid enrollment files. Telephone interviews were conducted with the child's parent or guardian between March and June 1998. An overall response rate of 70 percent was achieved, yielding a sample of 1,106 children (814 in MMC and 792 in Medicaid FFS).

PRINCIPAL FINDINGS

We find very few significant differences in access to, use of, or satisfaction with health care services for children under MMC relative to FFS. MMC did not change the patterns of health care service use or the location at which care is delivered, two major goals of MMC initiatives.

CONCLUSIONS

Our results suggest that the Medicaid program's shift from FFS to managed care had little impact on the pattern of children's health care use, the location at which they obtained care, or the satisfaction with the care they received.

Hospital and emergency department use by young low-income children

BACKGROUND

Limited data are available concerning determinants of health care service usage by low-income young children.

OBJECTIVES

To explore predictors of hospitalization and emergency department (ED) use by young children of low-income families by using the Aday and Andersen Access Framework.

METHODS

Low-income women (n = 474) with a child younger than 6 years completed a structured face-to-face interview at human service offices or Women, Infants, and Children (WIC) clinics in four central Ohio counties. Women were considered low-income if they or their child were Medicaid eligible or uninsured. Data were collected for both the mother and the index child on sociodemographic status, health services use, health status, and access to care.

RESULTS

Fifteen percent of the children had been hospitalized the previous year, and half had an ED visit. Hospitalization was significantly related to maternal hospitalization the previous year (OR = 2.5), child age younger than 1 year old (OR = 2.1) and more than two chronic conditions (OR = 2.2). Maternal ED usage in the last year (OR = 2.2), Medicaid fee for service plan (OR = 1.7), and rural residence (OR = 2.0) were predictive of ED use.

CONCLUSIONS

Predisposing characteristics (maternal hospital/ED use) were predictive of both hospitalization and ED use by the index child. Enabling characteristics (fee-for-service Medicaid plan, rurality) were only predictive of ED use, and need characteristics (child's health) were only predictive of hospitalization. Further research to explore linkages between maternal and child use of health care services as well as the effect of changes in health care access, managed care, and other innovations on hospitalization and ED use in young, low-income children is recommended.

Managed care and the pediatric emergency department

The growth of managed care has provided health benefits to millions of children while attempting to control the increase in health care costs. In adhering to these goals, MCOs are often at odds with emergency departments, and the emergency department physicians providing emergency care. The appropriateness or inappropriateness of emergency department visits can be disputed, but no criteria have been established. Even the definition of emergency is debated, although many states are adopting a prudent layperson standard. Emergency medicine physicians, primary care providers, and MCOs must cooperate to fully educate parents about the appropriate use of pediatric emergency services. Patients and MCOs should use facilities that can deliver pediatric emergency and critical care or provide appropriate transport systems to facilities that can. COBRA and EMTALA set the legal requirements to which emergency departments must comply when patients present for care. The basic caveats under COBRA require a medical screening examination for every patient and the stabilization of all patients with emergency medical conditions before inquiring about insurance or patients' ability to pay. A part of gatekeeping, MCOs often require authorization for treatment. MCOs authorize payment only. Evaluation and emergency treatment should not be withheld pending authorization. After the medical screening examination, recommended treatment should be in patients' best interests. All patients with potentially life-threatening conditions should be stabilized before transport, and all transfers must comply with the EMTALA. The transfer of unstable patients purely for economic reasons is a violation of the EMTALA. When stable, patients may be transferred to other facilities, but patients requiring specialty care should be taken to facilities best able to provide that care. Financial considerations should be superseded by medical necessity. Finally, improvements can be made in the way emergency medical service is provided to children within the current managed care system. The primary care provider is in a key position to inform parents about the types of pediatric emergencies, what to do in case one occurs, and to provide follow-up care. MCOs should incorporate clear information on pediatric emergencies. A mutual understanding of services needed, and how best to provide those services, are needed to forge a system that is responsive to children's emergency care needs.

Prenatal, intrapartum, and newborn care provided by health maintenance organizations: Medicaid versus commercial enrollees

A large majority of states have adopted a policy of enrolling Medicaid and other low-income populations in managed care organizations. Analysts have raised several questions relating to whether these populations will achieve appropriate access and utilization of services, including prenatal, intrapartum, and newborn care. Data from a national survey of health maintenance organizations are used to compare access to these kinds of care for Medicaid and commercial enrollees. Overall, utilization of services by the two populations is comparable.

The key to the door: Medicaid's role in improving health care for women and children

Medicaid is the nation's major public financing program for providing health insurance coverage and long-term care services to the poor. This article assesses Medicaid's contributions over the last three decades to improving the coverage, access to care, and health of low-income children and women. The article reviews Medicaid's impact on the low-income population covered by this program, demonstrating both the role insurance plays and its limitations as a strategy for improving the health of vulnerable populations. Medicaid has shown over the last three decades that it is an important lever to help open the door to better health care, and ultimately to improved health for America's poor women and children, by substantially expanding coverage of the low-income population and helping to reduce differentials in access to care between the poor and the privately insured. Gaps in coverage and limitations in access persist, but overall the program has resulted in better coverage, access, and health care for millions of poor children and their parents.

Assessing the quality of healthcare provided to children

OBJECTIVE

To present a conceptual framework for evaluating quality of care for children and adolescents, summarize the key issues related to developing measures to assess pediatric quality of care, examine some existing measures, and present evidence about their current level of performance.

PRINCIPAL FINDINGS

Assessing the quality of care for children poses many challenges not encountered when making these measurements in the adult population. Children and adolescents (from this point forward referred to collectively as children unless differentiation is necessary) differ from adults in two clinically important ways (Jameson and Wehr 1993): (1) their normal developmental trajectory is characterized by change, and (2) they have differential morbidity. These factors contribute to the limitations encountered when developing measures to assess the quality of care for children. The movement of a child through the various stages of development makes it difficult to establish what constitutes a "normal" outcome and by extension what constitutes a poor outcome. Additionally, salient developmental outcomes that result from poor quality of care may not be observed for several years. This implies that poor outcomes may be observed when the child is receiving care from a delivery system other than the one that provided the low-quality care. Attributing the suboptimal outcome to the new delivery system would be inappropriate. Differential morbidity refers to the fact that the type, prevalence, and severity of illness experienced by children is measurably different from that observed in adults. Most children experience numerous self-limited illness of mild severity. A minority of children suffer from markedly more severe diseases. Thus, condition-specific measures in children are problematic to implement for routine assessments because of the extremely low incidence and prevalence of most severe pediatric diseases (Halfon 1996). However, children with these conditions are potentially the segment of the pediatric population that can be most affected by variations in the quality of care. Improving the care provided to these children is likely to have the largest impact on quality of life and longevity. The low prevalence of most severe pediatric diseases also makes it difficult to evaluate the effectiveness of new treatment modalities; multi-center trials or long enrollment periods are usually required to obtain a large enough patient sample to conduct the necessary randomized controlled trials or cohort studies. Another challenge encountered when measuring quality of care for children is that, in most cases, they depend on adults to both obtain care and to report on the outcomes of that care. Parents and their children may have different perceptions of what defines health or have different levels of satisfaction with the care they receive. Children, particularly those with special needs, also depend on a broad range of services including the medical system, community intervention programs, social programs, and school-based services. Dependency on these various services adds to the difficulty of measuring and appropriately attributing health outcomes observed in children to a particular service delivery entity. Adolescents also depend on adults for access to some of their care; however, they have special needs related to confidentiality and parent-child information sharing. Adolescents commonly seek care at facilities, such as school-based clinics, that allow them to obtain confidential care. These facilities usually provide out-of-health plan care for these children, which raises special issues related to information availability for quality assessments and for assessing utilization patterns in this population. If the source of poor health outcomes is not known, quality improvement is not possible. The many challenges faced when constructing pediatric (this term will be used to refer to both children and adolescents) quality of care measures have resulted in few of these instruments being developed specifically for children. Most of the measures developed to date have either a very limited pediatric component or still require the process or outcome validation step. Although several practice guidelines and indicators of quality have been constructed, a conceptual framework to guide the development of such tools for quality assessment in the pediatric population is lacking.

CONCLUSIONS

Pediatric health services researchers and the organizations that fund this work need to focus on developing a set of quality assessment tools that will address several challenging issues. Working within the context of the conceptual framework presented, we draw several conclusions related to issues that should be considered in developing quality of care measures for children.

Health care utilization by children with chronic illnesses: a comparison of medicaid and employer-insured managed care

OBJECTIVES

This study compared utilization of health care services by children with chronic conditions who were insured by either Medicaid or an employer group in 1992 and 1993. Five chronic conditions were selected to illustrate patterns of service use: asthma, attention deficit disorder, diabetes, epilepsy, and sickle cell anemia.

METHODOLOGY

Administrative databases were used to develop estimates of health services utilization for children <18 years of age with the five selected conditions, who had been enrolled for at least 6 continuous months. All claims for a child identified with one of these five conditions were included in the analysis, including claims for diagnoses and procedures not directly related to the primary diagnosis. Estimates were derived for eight services (eg, hospital admissions, emergency department (ED), home health). Data were used from two Independent Practice Association model health plans in two states. Differences across the states were controlled by selecting one Medicaid and one employer-insured program from each of the two plans in both states. Regional variation was controlled for because both health plans were located in one geographical region. In each case, physicians were paid on a fee-for-service basis, with generally open access to specialists rather than primary care gatekeeper models of delivery: t tests were used to compare service use rates between Medicaid and employer-insured populations.

RESULTS

A total of 8668 children across all health plan groups had at least one of the selected conditions. Because Medicaid enrolled-children tended to be younger, analyses were adjusted for age. In both systems, a greater percentage of Medicaid children had these five study conditions (5%) compared with employer-insured children (3%), suggesting that the Medicaid population was sicker. Mean length of enrollment during the 2-year study was longer for children in employer-insured programs. Children with chronic conditions enrolled in Medicaid managed care generally used services at a higher rate compared with children with similar conditions enrolled in employer-insured managed care. The extent of the increased use varied by condition, by service type, and by plan. Children with any of the chronic conditions studied had from 2 to almost 5 times more ED visits if they were enrolled in Medicaid than if they were enrolled in employer-based managed care, depending on the specific condition. In one of the two plans, Medicaid-enrolled children had more outpatient services, laboratory services, and radiography services than their counterparts in employer-based managed care. The same pattern of use was found for home health services (except for children with diabetes) and for office visits (except for children with sickle cell). The results show higher use of all services by children with asthma and diabetes in Medicaid managed care compared with employer-based managed care. In contrast, the pattern is mixed for children with epilepsy and sickle cell. The sample size of children with these conditions was smaller than with the three other conditions, which may account, in part, for a varied pattern of results. The pattern of use for attention deficit hyperactivity disorder (ADHD) was generally different from the other conditions. Children with ADHD in employer-based managed care had more hospital admissions, hospital days, and office visits than their counterparts in Medicaid managed care. In contrast, Medicaid-enrolled children with ADHD had more ED visits, laboratory services, outpatient hospital visits, and radiography services. Other than ED visits, the differences in service use between Medicaid and employer-insured children with ADHD were minimal. Of note, the pattern for ADHD is the same for most services for Plans A and B (excluding home health visits). This utilization pattern may reflect service use for comorbid conditions. Part of this difference may be explained by differences in Medicaid e

Healthcare organizational change: implications for access to care and its measurement

OBJECTIVES

To summarize evidence from peer-reviewed literature on access to care for vulnerable HMO enrollee populations; to discuss the potential effect of recent HMO and physician organization changes on access to care and its measurement.

STUDY DESIGN

Review and summary of peer-reviewed literature for two HMO populations: those with chronic conditions and diseases, and those subject to discrimination due to income, color, or ethnic background. I also reviewed and summarized literature on three major changes in capitated organizations (HMOs and capitated physician organizations) that could affect access to care for vulnerable populations, and summarized findings from healthcare manager interviews conducted for several recent research projects on health system change.

PRINCIPAL FINDINGS

Although mixed, there are enough negative results to raise some concerns about access to care for HMO enrollees with chronic conditions and diseases. Several emerging organizational changes have the potential to change access to care for the vulnerable HMO enrollees. The shift in cost-cutting from fragmented clinical management of specific services at a point in time toward more integrated clinical management of all services for specific types of patients across time may improve access to care, as may increased efforts to attract and retain HMO enrollees. The increased importance of capitated provider organizations within the health system may restrict access in some ways, and expand access in others.

CONCLUSIONS

Organizational changes can affect both access to care and its measurement. More research is needed on the effects of these changes on access to care and quality of care. For researchers examining access to care for vulnerable HMO enrollee populations, these changes create challenges to determine the most appropriate measures of access to care, and the most appropriate organizations and organizational characteristics to measure. RELEVANCE TO CLINICAL PRACTICE, MANAGEMENT, AND/OR POLICY: Changes in market competition are leading to organizational changes that affect access to care for vulnerable HMO enrollee populations. Public and/or private policies that improve measurement and reporting can affect market competition and improve access to care.

Early and periodic screening, diagnosis, and treatment and managed care

This paper presents evidence on the performance of Medicaid managed care organizations (MCOs) in providing Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services to children under age 21. States face considerable challenges in integrating EPSDT into managed care. For example, MCOs rarely offer all services required under federal law. Also, MCOs often are unable to meet state reporting requirements. On the other hand, MCOs offer children a medical home, often for the first time, that may encourage timely preventive care. The literature generally shows no differences in the performance of MCOs relative to traditional FFS providers in the EPSDT participation rate. Future needs include improving the specificity of contract language, more precisely defining the EPSDT benefit package, evaluating the adequacy of EPSDT payments, monitoring the capacity of MCO provider networks, establishing the effectiveness of outreach and enabling services, developing standardized MCO reporting requirements, documenting program outcomes, and assessing benchmarks for accountability.

Impact of a Medicaid primary care provider and preventive care on pediatric hospitalization

OBJECTIVE

This study evaluates the impact that a Medicaid managed care program had on avoidable hospitalization, a form of health care misuse that we hypothesize can be reduced by improved access to and quality of primary care in the context of a managed care program. Ambulatory care sensitive (ACS) hospitalizations, a previously defined categorization of hospitalization, as well as all pediatric hospitalizations were also studied.

INTERVENTION

The Maryland Access to Care (MAC) was a fee-for-service, gatekeeper, Medicaid managed care program with assigned primary medical providers and required Early Periodic Screening, Diagnosis, and Treatment (EPSDT) examinations. Medicaid managed care elements include: 1) assignment to primary medical provider (PMP) either by voluntary choice or mandatory enrollment of eligible Aid to Families With Dependent Children (AFDC), Medical Assistance (medical needy), and Supplemental Security Income; 2) a medical home accessible 24 hours a day, 7 days a week; 2) PMP must authorize emergency department (ED), inpatient, and specialty care but there were no disincentives to PMP for referral; 3) fee-for-services reimbursement (with a physician rate increase) for primary care, authorized specialist care, and hospitalization; and 4) an on-line eligibility verification system was available to all medical providers. Pre-enrollment as well as publicity allowed MAC to be phased in rapidly, resulting in 70% to 80% enrollment by the end of the first program year.

DESIGN

The design of this study is that of a pre- and postevaluation of the MAC program using Medicaid claims analysis of data 3 years pre-MAC and 2 years post-MAC. In multivariate analyses, this study also compares MAC-enrolled children to non-MAC-enrolled children (before and after MAC began) to estimate the impact of MAC enrollment while controlling for potential confounders.

SETTING

State of Maryland from 1989 to 1993.

PATIENTS

MAC-eligible children 18 years of age.

OUTCOME MEASURES

Claims data were used to define avoidable hospitalization (based on ambulatory care received before hospitalization), to define ACS hospitalizations (based on the International Classification of Diseases-Clinical Modification, Ninth Revision [ICD-9-CM] codes), and to summarize use of ambulatory and inpatient care. ACS hospitalizations have been defined as those conditions for which timely and effective primary care can help to reduce the risk of hospitalizations. These are based solely on ICD-9-CM discharge codes that were studied by Billings and Teicholz in 1990 and used by an Institute of Medicine report in 1993. Examples include hospital discharge diagnoses of asthma (ICD-9-CM = 493), gastroenteritis (ICD-9-CM = 558.9), and dehydration (ICD-9-CM = 276.5). Usage measures, such as preventive care visits or ED visits, were created using Maryland Medicaid codes, Current Procedural Terminology codes, and ICD-9-CM codes. Linear regression was used to model trend. Logistic regression was used to model the probability of ambulatory and inpatient care given MAC enrollment and other covariates. First, logistic regression was used to predict the probability of any ambulatory care use among all MAC-eligible children during a quarter to model changes in access that may have occurred during MAC. Then, among users of ambulatory care or inpatient care, logistic regression was used to predict the probability of hospitalization.

RESULTS

Most of the children studied were in the AFDC program, about half were African-American, one third resided in Baltimore City, and 9% of children had ICD-9-CMs reflecting chronic disease. The mean percentage of time children were MAC-eligible per quarter was 91%. Only 5% of children were continuously enrolled for all 20 quarters included in this study. Per-capita ambulatory care visits, especially per-capita preventive care visits, increased significantly during the study period (b = 0.003) whereas per-capita ED visits did not change. The mean n

Children's Use of Primary and Preventive Care Under Medicaid Managed Care

The authors found that two mandatory Medicaid primary care case management (PCCM) programs were somewhat successful in improving access to primary care among children in the early 1990s. However, the Florida program, in which the PCCM benefit package included Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services, did not meaningfully increase EPSDT screening visits among preschoolers. Further, the increase seen in New Mexico, where EPSDT was carved out of the PCCM benefit package, was evident for both program participants and non-participants and therefore could not be attributed to the PCCM program.

Health care utilization by the elderly in HMOs: comparing risk and cost contracts

Data are utilized collected from the American Association of Health Plans, a trade association representing HMOs, to study differences in utilization patterns between medicare beneficiaries enrolled in Medicare risk and cost contracts with health plans. Utilization is measured by the number of ambulatory procedures performed, outpatient and emergency room visits, and acute and nonacute discharges. Compared to elders enrolled in risk plans, those in cost arrangements appear to exhibit higher inpatient and outpatient use. Members of for-profit plans experienced greater outpatient visits, accreditation did not appear to influence utilization, and IPA arrangements resulted in a decrease in outpatient utilization. Financial and policy issues are discussed.

Social HMOs and other capitated arrangements for children with special health care needs

OBJECTIVE

Children with special health care needs are increasingly enrolling in managed care arrangements. However, existing managed care organizations, including traditional HMOs, are often poorly suited for caring for this population. In the adult health care area, new managed care entities, called Social HMOs (S/HMO) and Programs for the All-inclusive Care for the Elderly (PACE), have been created to integrate health and health-related services for chronically ill and disabled adults. We describe these models and assess their potential for serving children with special health care needs.

METHOD

We reviewed the literature on managed care for children with special health care needs and evaluation findings from the S/HMO and PACE models for the elderly.

RESULTS

Evaluations of the S/HMO and PACE models have yielded mixed findings. Some of the more positive accomplishments include lower use and expenditures for long-term care services compared to other demonstration projects, greater integration of primary care physicians in decision making concerning long-term care, and improved management of transitions between care levels. On the negative side, start-up has been slow, prospective members have been hesitant to enroll, intermittent and sometimes frequent operating deficits have emerged, no discernible positive effects on health or social outcomes are apparent, and no significant overall savings have emerged.

CONCLUSIONS

With mixed results so far, caution is required in applying these or similar models for vulnerable child populations. However, given the inadequacies of traditional managed care for this population, we believe experimentation with new models of care that integrate health and health-related services is important. Such experimentation should be fostered only to the extent that the models are carefully designed and then implemented in a manner that protects the interests of children with special health care needs.

Medicaid managed care policies affecting children with disabilities: 1995 and 1996

The authors present findings from a study of State Medicaid managed care enrollment and benefit policies in 1995 and 1996 for children with disabilities. During this time the number of States serving children through fully capitated plans grew by more than one-third, and enrollment of children receiving Supplemental Security Income (SSI) payments and children in subsidized foster care increased. Most States required plans to provide all mandatory and most optional Medicaid services. Although States have begun to make noticeable improvements in their contract language concerning medical necessity and the early and periodic screening, diagnosis, and treatment (EPSDT) benefit, overall State guidance in these areas remains weak.

Medicaid health maintenance organizations. Can they reduce program spending?

A randomized trial to evaluate the Florida site of the Program for Prepaid Managed Care showed that the plan, a staff model health maintenance organization, was successful in attracting Medicaid enrollees. The evaluation established that the health maintenance organization was able to limit members' utilization. The savings were in the form of lower likelihood of using care. The amount of services received, once care was initiated, was the same in both fee-for service Medicaid and health maintenance organizations. The authors detected no differences in inpatient use or costs. Additionally, they found evidence that the plan attracted sicker than average enrollees, so this reduced utilization translates into Medicaid program savings.